Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palolo Chinese Home during CMS and state inspections, most recent first.
Failure to Protect Resident from Physical Abuse: A CNA willfully pushed a resident’s head without a care-related purpose after frustration during toileting and transfer assistance. Another CNA directly witnessed the resident being struck on the head, and the resident later stated he had been slapped and was shocked because he had a good relationship with the CNA. The DON confirmed the action was not related to care and the facility determined the incident was physical abuse.
Delayed Reporting of Suspected Abuse: A CNA witnessed another CNA strike a resident in the head, but did not immediately report the suspected abuse to the DON because of fear of retaliation. The allegation was later reported to the IP, and the facility’s State Agency report was submitted days after the incident. The DON confirmed staff are required to immediately report suspected abuse and that the accused CNA continued to care for the resident during the delay.
A facility failed to ensure an agency staff member who was a full-time employee completed the required nurse aide training and competency evaluation program within 4 months of hire. Record review showed no start date, license number, or expiration date for the aide, and the Administrator confirmed the aide was not certified, had only on-the-job caregiver training, and should not have worked in the LTC program.
A facility failed to ensure that agency staff 10, who provided nurse aide services, was listed on the state nurse aide registry before working in the facility for a facility-reported staff-to-resident abuse allegation. The Administrator confirmed the staff member did not meet CNA competency or certification requirements and had only received on-the-job caregiver training, and the DON agreed the registry should be verified before hiring staff.
A resident with a recent stroke was admitted for rehabilitation, but staff failed to update the care plan to address stroke-related risks or implement aspiration prevention measures. The resident developed a moist cough and respiratory distress, with staff not recognizing early signs of aspiration, failing to communicate key symptoms to the physician, and not administering ordered treatments. The family ultimately requested hospital transfer after observing the resident's decline, and the resident was admitted in respiratory distress and later placed on hospice.
A resident's medical record contained late entries by nursing staff, resulting in incomplete documentation and failure to communicate important care instructions, such as keeping the head of bed elevated. Additionally, a nurse documented physician notification about the resident's improved respiratory status, but the physician confirmed this communication did not occur.
The facility did not provide residents or their representatives with the grievance official's contact information or inform them of their right to receive written findings of grievance investigations. Additionally, in several reviewed grievances, the facility failed to document investigation findings, conclusions, or corrective actions taken.
The facility did not ensure that contract nursing assistants received adequate abuse prevention training, as required by policy. Review of staff files and agency contracts showed that several contracted CNAs lacked proper documentation or evidence of comprehensive abuse training, and facility leadership relied on agencies to provide this training without verifying its content. This resulted in a failure to protect residents' health, welfare, and rights by not fully implementing abuse prevention policies and procedures.
A nurse in the admissions office accessed a former resident's hospital medical records through an online portal after the resident left the facility AMA and was not expected to return. This access occurred without the resident's consent and after the treatment relationship had ended, violating facility policy and confidentiality agreements.
A resident with multiple chronic conditions reported waking to find someone in her bed who pulled down her undergarment and left. Facility staff did not identify this as potential abuse and failed to notify required authorities, including OHCA, APS, or police, despite policy requiring immediate reporting of such allegations. Staff interviews revealed confusion about reporting responsibilities, and the incident was handled as a grievance rather than a reportable event.
A resident reported waking up to someone lying in bed with her and having her brief pulled down, but the facility did not identify this as potential abuse or report it to the appropriate authorities. The internal investigation was incomplete, missing interviews with the roommate and several staff, lacking a summary of video surveillance findings, and failing to document a clear conclusion. Required investigative steps outlined in facility policy were not followed, resulting in an incomplete response to the allegation.
Two residents experienced delayed staff response to call lights, with wait times ranging from 25 minutes to an hour for assistance with urgent care needs, including incontinence and fall risk. Additionally, a resident with hemiplegia reported that staff did not respect his privacy by failing to knock or close the bathroom door as requested, and made him wait 30 minutes for toileting assistance. The DON acknowledged these lapses and confirmed that not all complaints were formally investigated.
A resident with hemiplegia, hemiparesis, and bilateral amputation, who was cognitively intact, requested a one-arm-drive wheelchair to maintain independence in ADLs and participate in activities. Despite a therapy evaluation supporting this need, the facility did not provide timely follow-up or ensure the resident received the requested wheelchair, limiting his ability to leave his room and participate as desired.
Two residents were not supported in their right to make choices about significant aspects of their daily lives. One resident, who prefers morning oral hygiene, was routinely assisted with brushing teeth much later than desired. Another resident on hospice was left in a wheelchair for extended periods, contrary to family and representative requests for limited time out of bed. The DON confirmed that staff actions did not align with the expressed preferences of these residents.
The facility did not obtain or properly document Advance Health Care Directives (AHCD) for two residents. In one case, there was no documented follow-up with a hospice provider to obtain the AHCD, and in another, a late entry was made after a reminder from leadership, with the resident not recalling recent discussions. Both Social Services staff acknowledged that AHCD documentation should be completed quarterly and entered promptly, but this was not done.
Two residents experienced deficiencies related to environmental cleanliness and protection of personal property. One resident found soiled incontinence items left on her belongings by staff, while another had his personal lamp removed without explanation or documentation of consent. Facility staff did not follow procedures for prompt disposal of soiled items or for communicating and documenting the removal of resident property.
Two residents did not have comprehensive care plans addressing their specific medical needs, including insulin administration for diabetes and oxygen therapy for respiratory care. Despite physician orders and facility policy, the care plans failed to include necessary interventions, as confirmed by record reviews and staff interviews.
A nurse left medications unattended on a resident's bedside table while stepping out of the room to get gloves, making the medications accessible to others. The nurse and DON both acknowledged this was against facility policy, which requires staff to remain with the resident during medication administration and not leave medications in the room without specific orders.
A resident with documented food allergies did not receive the meal he had selected in advance, as the kitchen substituted other items due to his allergies without informing him or offering alternative choices. The resident was confused and dissatisfied when served a meal that did not match his preferences, and staff failed to communicate the reason for the change prior to service.
Two residents requiring modified diets for dysphagia were served meals that did not meet the physician-ordered chopped consistency, with food items observed to be inconsistent in size and not properly prepared. Staff interviews confirmed a lack of clear standards for food preparation, and the facility did not follow established guidelines for chopped diets.
Staff did not check or document the temperature of one kitchen refrigerator during the evening shift for two consecutive days. The temperature log was missing entries and staff initials, and both the EC and DON confirmed that daily temperature checks are required to prevent food spoilage.
Staff failed to properly dispose of a soiled incontinence item by leaving it on a resident's personal belongings, and did not use the required PPE, specifically a gown, while providing direct care to a resident under enhanced barrier precautions for a skin rash. These actions did not follow facility infection control policies and procedures.
A resident with a history of recurrent falls and a recent femur fracture was not accurately assessed for the use of bed and chair alarms as fall prevention interventions. Although staff documented the use of these alarms in progress notes, they were not included in the care plan or reflected in the MDS assessment during the relevant period, resulting in an incomplete assessment of the resident's care needs.
The facility did not update care plans for two residents after significant changes in their conditions. One resident, with a history of falls, suffered a major injury and was readmitted without new fall prevention interventions being added to the care plan, leading to additional falls. Another resident with a urinary catheter did not have catheter care included in the care plan after reinsertion, despite physician orders and facility policy requiring such updates.
Two residents experienced falls with major injuries due to the facility's failure to provide adequate supervision, follow proper transfer protocols, and update care plans with new interventions after significant incidents. One resident was transferred incorrectly by a single CNA unfamiliar with her needs, resulting in a fracture, while another resident with a history of falls did not have new fall prevention measures added to her care plan after a major injury, leading to further falls.
Nursing staff failed to accurately complete fall risk assessments for three residents, resulting in inconsistent and incomplete evaluations following multiple falls, including incidents with major injuries. The DON confirmed that assessments were improperly completed and did not reflect the residents' true risk status, particularly in the areas of gait, balance, and medications.
A resident sustained an unwitnessed fall in the dining room due to the facility's failure to implement care plan interventions. The care plan required supervision of common areas, but a lapse in communication left the resident unsupervised for five minutes after family left, during which the fall occurred. Interviews confirmed the lack of supervision and adherence to the care plan.
Two residents with severe cognitive impairment and high fall risk scores experienced falls due to inadequate supervision. One resident was left unsupervised in the courtyard and sustained a head laceration, while the other fell unwitnessed in the dining room despite care plan instructions for constant supervision in common areas.
A resident with a history of Moyamoya disease and other conditions experienced a delay in care after her spouse reported a limp left arm to a CNA, who failed to notify a nurse. The resident was later diagnosed with a left upper arm fracture. The facility's policy requires staff to report changes to the RN on duty, which was not followed, leading to a delay in treatment.
A facility failed to ensure proper PPE use for a resident under contact precautions. A Radiologist Technologist and a CNA entered the resident's room without wearing gowns, despite a sign indicating contact precautions. The DON confirmed that gowns and gloves should be worn, aligning with the facility's policy to minimize exposure to infectious materials.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from abuse when a CNA willfully pushed the resident’s head without a care-related purpose. The incident involved R12, who was in his room with his roommate when CNA30 reportedly heard a back-and-forth conversation between R12 and CNA19 and then witnessed CNA19 strike R12 on the head. The event report stated CNA30 saw the resident struck twice on the head, once on the back of the head and once on the side of the head, and later assisted with transferring R12 back to bed. R12 later stated he was okay, but the report also documented that he told CNA30 CNA19 had slapped him the previous week. The facility’s investigation included interviews with CNA19, CNA30, R12, the IP, the DON, and the Administrator/Assistant Administrator. CNA19 stated she used one finger to push the back of R12’s head one time and said she was frustrated after assisting him to the toilet and having difficulty transferring him back to bed. CNA30 confirmed she directly witnessed CNA19 hit R12 on the back and side of the head with an open hand, causing his head to jerk forward slightly and making an audible sound. R12 stated CNA19 slapped him and said he was shocked because he had a good relationship with her. The DON stated CNA19 should not have placed her hands on the resident because the action was not related to providing care, and the facility concluded the incident was physical abuse.
Delayed Reporting of Suspected Abuse
Penalty
Summary
The facility failed to ensure that a staff member who witnessed another staff member willfully hit a resident in the head immediately reported the incident to the administrator. The incident involved R12, and the facility’s investigation showed that CNA30 witnessed CNA19 strike R12 twice on the head, once on the back of the head and once on the side of the head, without a care-related purpose. The facility’s initial event report to the State Agency was not submitted until eight days after the alleged incident. The investigation file showed that CNA30 did not report the incident immediately because she feared retaliation from CNA19, who had assisted her with housing and was a contract staff member. CNA30 later reported the allegation to the IP, who then instructed her to formally report it and provide a written statement because the allegation involved potential resident abuse. The DON confirmed that staff are required to immediately report any suspicion of abuse and acknowledged that CNA30 delayed reporting. The DON also confirmed that CNA19 continued to work with R12 after the incident because of the delay in reporting.
Uncertified Nurse Aide Worked Without Required Competency Evaluation
Penalty
Summary
The facility failed to ensure that agency staff 10, identified as a full-time employee, completed the required nurse aide training and competency evaluation program or a State-approved competency evaluation program within four months of hire. During record review, the facility document titled "Agency Staff Checklist for Credentials" showed no specific start date for NA10, and the certification information did not include a license number or expiration date, indicating the individual was not certified. In interview, the Administrator confirmed that AS10 did not meet competency evaluation requirements or have nurse aide certification, stated that AS10 received on-the-job training for caregiver duties but would not be appropriate for the facility's LTC program, and acknowledged that AS10 should not have worked in the LTC facility. The facility's CNA job description also stated that staff must have current CPR and Hawaii CNA certification.
Failure to Verify Nurse Aide Registry Status Before Use
Penalty
Summary
The facility failed to ensure that agency staff 10, who was providing nurse aide services, was listed on the state nurse aide registry before working in the facility for one of three facility-reported staff-to-resident abuse allegations reviewed (Intake #2659390). During an interview on 05/21/26 at 11:12 AM, the Administrator confirmed that AS10 did not meet competency evaluation requirements and did not have a nurse aide certification. The Administrator also stated that AS10 had received on-the-job training as a caregiver but would not be appropriate for the Long-Term Care program, and agreed that AS10 should not have worked in LTC. During an interview on 05/21/26 at 09:19 AM, the DON confirmed that the facility should verify the nurse aide registry prior to hiring staff and agreed with that expectation.
Failure to Identify and Intervene in Acute Change of Condition Following Stroke
Penalty
Summary
Facility staff failed to identify and appropriately intervene in an acute change in condition for a resident who had recently suffered multiple strokes and was admitted for rehabilitation. The resident's care plan did not address the recent stroke or include standard interventions for stroke patients, such as elevating the head of the bed to prevent aspiration. Staff did not recognize the resident's occasional moist cough during meals as a potential early sign of aspiration, nor did they communicate this symptom to the physician. Documentation was inconsistent, with conflicting information about the resident's distress when positioned on his back, and the care plan lacked necessary interventions for aspiration prevention. On the evening of admission, the resident developed an increased moist cough and audible congestion, with oxygen saturation dropping to 78%. Staff performed suctioning and notified the physician, who ordered Duoneb and Robitussin for cough and respiratory symptoms. However, staff did not administer these medications as ordered. Progress notes included late entries after the resident was discharged, and there was a lack of timely and accurate communication among staff and with the physician regarding the resident's symptoms and response to interventions. The family was not kept adequately informed of the resident's deteriorating condition and ultimately had to request hospital transfer after observing significant respiratory distress the following morning. Interviews with nursing staff revealed gaps in hand-off communication and a lack of prompt action in response to the resident's low oxygen saturation and persistent symptoms. The physician was not informed that the resident's cough occurred during oral intake, which may have influenced the care plan. The Director of Nursing confirmed that the care plan should have addressed the resident's stroke diagnosis to prevent aspiration. As a result of these deficiencies, the resident was admitted to the hospital in respiratory distress due to aspiration and subsequently placed on hospice care.
Failure to Maintain Accurate and Timely Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate and timely documentation in the medical record for one resident, resulting in incomplete records and lack of communication regarding care instructions. Specifically, a registered nurse entered a late progress note into the electronic health record after the resident had already been discharged to the hospital, documenting that the head of bed should remain elevated, but this information was not communicated to staff in a timely manner. Additionally, another nurse wrote a late progress note indicating that a physician had been notified about the resident's decreased coughing and wheezing, but the physician confirmed that this notification did not occur. These late entries led to incomplete and inaccurate documentation of the resident's condition and care provided.
Failure to Provide Grievance Official Information and Written Grievance Outcomes
Penalty
Summary
The facility failed to provide residents and their representatives with the name and contact information of the grievance official, and did not inform them of their right to receive the findings of grievance investigations and conclusions in writing. Policy documents and the admission handbook only referenced oral communication of findings and did not include the required written notification or the grievance official's contact details. During a walkthrough, no posting of the grievance official's name and contact information was observed in the facility. Additionally, review of three resident grievance reports revealed that findings, conclusions, and corrective actions were not documented. In one case, a resident's family reported an incident involving someone entering the resident's bed at night, but the internal investigation summary and follow-up were missing. Another resident complained about staff responsiveness and behavior, but the facility did not document the internal investigation or any actions taken. In a third case, a family member reported concerns about a CNA being too rough, but the investigation summary, corrective action, and communication to the family were not documented in the report.
Failure to Ensure Contract Staff Receive Required Abuse Prevention Training
Penalty
Summary
The facility failed to develop and fully implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility's policy did not address how contract or agency caregivers would receive the required abuse prevention training, except for a brief mention of burnout identification. A review of contract staff files revealed that four out of six contracted nursing assistants lacked evidence of having completed the required abuse prevention training, or the documentation provided was insufficient in content and validation. For example, some training only included minimal or irrelevant content, such as questions about child abuse or intimate partner violence, and others were not properly graded or did not cover all required elements. Interviews with facility leadership, including the ADON, Administrator in Training, CEO, and Human Resource Director, revealed inconsistent practices regarding the orientation and training of contract staff. The ADON admitted to signing off on orientation checklists without directly observing competency demonstrations and stated that only a limited portion of abuse training was provided by the facility, with the expectation that agencies would cover the rest. However, there was no verification that agency-provided training met facility or regulatory requirements. The HRD confirmed that review of agency training content was not part of her process, leaving gaps in oversight. A review of contracts with staffing agencies further demonstrated that most agreements did not specify requirements for abuse prevention training or orientation to facility policies. Some contracts placed the responsibility for orientation and training on the facility, while others were silent on the issue. As a result, there was no assurance that contract staff received adequate training to recognize and prevent abuse, neglect, or exploitation, leading to a deficiency in protecting the health, welfare, and rights of residents.
Unauthorized Access to Former Resident's Medical Records After Discharge
Penalty
Summary
A deficiency occurred when a registered nurse working in the admissions office accessed the external hospital medical records of a resident through an online portal after the resident had left the facility against medical advice (AMA) and with no intention to return. The nurse used the hospital's portal, which is intended for reviewing records of patients being referred or expected to return to the facility, to access the resident's emergency department records the day after the resident's departure. This access was performed without the resident's consent and after the treatment relationship had ended. The resident involved was an older female with a complex medical history, including chronic kidney disease, urinary retention requiring a suprapubic catheter, recurrent urinary tract infections, bladder cancer, and chronic pain. Facility policies, the hospital-facility agreement, and user confidentiality agreements all required that medical records be accessed only for individuals with an authorized treatment relationship and with appropriate consent. The nurse's actions violated these requirements, resulting in a breach of confidentiality and the resident's rights.
Failure to Report Alleged Abuse to Authorities
Penalty
Summary
The facility failed to report an allegation of potential abuse involving a female resident who had recently been discharged from the hospital for acute kidney injury and other chronic conditions. The resident reported that she awoke to find someone lying next to her in bed, who then pulled down her undergarment and left the room quietly. Despite this report, the facility did not identify the incident as potential abuse and did not notify the required external authorities, including the Office of Healthcare Assurance (OHCA), Adult Protective Services (APS), or the police. Interviews with facility staff revealed confusion and a lack of consensus regarding the reporting requirements for such incidents. The Social Services Coordinator stated that nursing was responsible for reporting to the state and social services to APS, but admitted she did not report the incident. The Assistant Director of Nursing (ADON) did not perceive the incident as abuse or a crime, and therefore did not notify authorities, believing the event could have been related to patient care. The ADON also indicated that the incident was not reported because there was no confirmation of abuse or sexual contact at the time. Further, the Administrator in training and the Chief Executive Officer both stated that the incident was handled as a grievance rather than a reportable event. They believed that since the initial investigation did not find evidence of abuse and the sexual allegation was raised after the resident left the facility, it was not their responsibility to report. The facility's own policy, however, required immediate reporting of suspected abuse or sexual assault to law enforcement and state agencies, which was not followed in this case.
Failure to Thoroughly Investigate and Document Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an alleged abuse incident reported by a resident who stated that she woke up with someone lying next to her in bed and that her brief had been pulled down, exposing her. The facility did not identify this incident as potential abuse and did not report the allegation or the results of their internal investigation to the Office of Healthcare Assurance as required. The investigation was led by the Assistant Director of Nursing, who interviewed the resident and reviewed video surveillance, but the documentation of the investigation was incomplete and not in sequential order, with missing times and unclear formats for staff statements. Key investigative steps were omitted, including not interviewing the resident's roommate, who may have had relevant information, and not obtaining statements or interviews from three CNAs and an RN who were assigned to the unit during the period in question. The facility's policy specifically required obtaining statements from roommates when applicable, but this was not done. Additionally, the investigation notes did not include a summary of the findings from the surveillance camera review or correlate these findings with staff statements and interviews. The documentation provided by the facility lacked a clear summary and conclusion of the investigation. Several staff statements were undated or dated several days after the incident, and it was unclear whether they were written or obtained through interviews. The investigation record also did not include a comprehensive assessment of the resident by the nurse, as the lower abdomen and pelvic area were not examined. These omissions resulted in an incomplete investigation and failure to meet regulatory requirements for responding to and documenting alleged violations.
Failure to Ensure Resident Dignity and Timely Response to Care Needs
Penalty
Summary
The facility failed to ensure residents' rights to a dignified existence and timely care, as evidenced by multiple incidents involving delayed staff response to call lights and lack of respect for residents' privacy. One resident reported that staff response to call lights was inconsistent, with a specific incident where a call light was activated for a roommate whose legs were dangling off the bed, and staff took approximately 25 minutes to respond. The resident's representative also described two separate occasions where family members waited 30 minutes to an hour for staff to respond to call lights to address the resident's incontinence needs. The Director of Nursing acknowledged that these response times were excessive and not in line with facility expectations. Another resident, who was cognitively intact and had hemiplegia and hemiparesis following a stroke, reported that staff did not knock or ask permission before entering his room and failed to close his bathroom door as requested, despite signage instructing staff to do so. The resident also stated that a CNA made him wait 30 minutes before assisting with toileting. The Director of Nursing confirmed that not all of the resident's complaints had been formally investigated and agreed that the resident should have been treated with respect and dignity, as outlined in the facility's policy.
Failure to Timely Provide One-Arm-Drive Wheelchair Limits Resident Independence
Penalty
Summary
A male resident with a history of hemiplegia and hemiparesis following a stroke, as well as bilateral amputation, was re-admitted for long-term care. The resident was cognitively intact and expressed a desire to participate in activities outside his room, but reported limited mobility as a barrier. On a specific date, he requested a one-arm-drive wheelchair to enable him to safely and independently perform activities of daily living, including grooming, dressing, and toileting. A physical therapy evaluation documented that the resident required a wheelchair for functional mobility and would achieve maximum independence with a one-arm-drive wheelchair. Despite the resident's request and the therapy recommendation, facility records showed that the request for the specialized wheelchair had not been addressed in a timely manner. The Social Services Coordinator confirmed that the facility was still waiting for an update from the supplier months after the initial request, and the DON acknowledged there was no documentation of timely follow-up. The facility's policy states that residents have the right to participate in social activities at their discretion, but the lack of timely action to accommodate the resident's mobility needs resulted in the deficiency.
Failure to Support Resident Choice in Daily Care and Positioning
Penalty
Summary
The facility failed to honor and support resident self-determination and choice for two residents. One resident, who prefers to brush her teeth three times a day, specifically upon waking and after each meal, reported that staff often delayed assisting her with oral hygiene until late morning or even around lunchtime, despite her preference for morning care. Documentation of oral hygiene tasks confirmed that assistance was most frequently provided in the late morning or afternoon, rather than at the times preferred by the resident. The Director of Nursing acknowledged that the timing of oral care did not align with the resident's stated preferences. Another resident, who is on hospice care and has a weakened physical state, was observed seated in a wheelchair in the dining room for extended periods, including sleeping in the chair, despite family and resident representative requests that the resident not remain in the wheelchair for more than 15-20 minutes at a time. Family members and the resident representative reported that the resident could not tolerate prolonged periods in the wheelchair and had communicated this to staff. Observations and interviews confirmed that the resident was left in the wheelchair for longer than requested, and the Director of Nursing confirmed this was not in accordance with the family's wishes.
Failure to Obtain and Document Advance Health Care Directives
Penalty
Summary
The facility failed to obtain and document Advance Health Care Directives (AHCD) for two residents. For one resident, the electronic health record showed a note indicating that Social Services would follow up with the hospice provider regarding the AHCD, but there was no documentation of any follow-up attempts. The Social Services Coordinator confirmed that no further action was taken to obtain the AHCD and acknowledged that alternative contacts, such as the visiting nurse from the hospice provider, were not pursued. For the second resident, no AHCD was found in the electronic health record, and the Director of Nursing was unable to provide documentation. A late entry was made by the Social Worker, documenting a prior discussion in which the resident refused an AHCD, but this was only entered after a reminder from leadership. The resident recalled an initial discussion about the AHCD upon admission but did not remember any recent conversations. Both the Social Worker and Social Services Coordinator agreed that AHCD documentation should be completed quarterly and entered promptly into the electronic health record, but this was not done in a timely manner.
Failure to Maintain Clean Environment and Protect Resident Property
Penalty
Summary
The facility failed to maintain a clean, homelike environment and did not adequately protect residents' personal property. In one instance, a cognitively intact resident was found with a used incontinence bed pad and used gloves left on top of her personal belongings, including a green bag with arts and crafts supplies and a reusable bowl. The soiled items were not disposed of properly, despite a trash bin being available nearby. The resident reported that she did not place the items there and indicated that agency staff sometimes left dirty items in her room. Facility policy required prompt disposal of soiled linens to minimize odors, but this was not followed. In another case, a cognitively intact male resident reported that his personal floor lamp was removed from his room by maintenance after it broke, but he was not given an explanation or offered a replacement. There was no documentation of his consent for the removal or any explanation provided to him. Interviews with staff revealed confusion about the removal process, and the lamp was later found in the MDS office. The facility did not document the removal or communicate adequately with the resident regarding his property.
Failure to Develop and Implement Comprehensive Care Plans for Insulin and Oxygen Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents, as identified through observation, interview, and record review. For one resident with an order for Insulin Glargine administered via a sliding scale, there was no corresponding care plan addressing the use of insulin. This was confirmed during a review of the resident's electronic health record and through interviews with the Director of Nursing, who acknowledged the absence of a care plan for insulin administration despite the physician's order. Another resident, who was observed receiving oxygen therapy via nasal cannula, also lacked a care plan addressing respiratory care, including oxygen administration. Interviews with an LPN and the Director of Nursing confirmed that the resident's care plan did not include interventions or evaluations related to respiratory care, despite physician orders for oxygen and facility policy requiring such interventions to be documented in the care plan. The resident's diagnoses included vascular dementia and an order for oxygen therapy with specific parameters, but these were not reflected in the care plan.
Medications Left Unattended During Administration
Penalty
Summary
A registered nurse was observed administering medications to a resident and left multiple medications unattended on the resident's bedside table while leaving the room to obtain the correct size glove. During this time, the medications were accessible to anyone who could have entered the room. The nurse acknowledged that medications should not have been left out of sight and recognized the safety concerns associated with this action. The Director of Nursing confirmed that medications should not be left unattended for safety reasons. Review of the facility's Medication Administration policy indicated that staff are required to remain with the resident while medication is swallowed and not to leave medications in a resident's room without specific orders to do so.
Failure to Follow Resident Menu Preferences and Communicate Food Substitutions
Penalty
Summary
The facility failed to ensure that a resident's menu selections and food preferences were followed, resulting in the resident receiving a meal that did not match his advance selections and included items he did not want. The resident, who has documented allergies to pineapple and turkey, had selected beef tomato, rice, and mandarin oranges for lunch, as indicated on his posted menu. However, the kitchen substituted chicken and cauliflower for the selected items without prior communication or explanation to the resident. The substitution was made because the beef tomato contained pineapple, and the alternative entrée, turkey burger, was also not suitable due to the resident's allergy. The resident was not informed of these changes or given the opportunity to choose from other available menu options prior to being served. During the lunch observation, the resident expressed confusion and dissatisfaction with the meal provided, noting that his selected items had been crossed out and replaced without his input. The resident only learned after the fact that the substitution was due to his allergies, and he was not approached beforehand to discuss alternative choices. The lack of communication and failure to follow the resident's documented food preferences led to the resident receiving a meal he did not want, causing confusion and dissatisfaction during the dining experience.
Failure to Provide Physician-Ordered Food Consistency for Residents with Dysphagia
Penalty
Summary
The facility failed to provide food in the physician-ordered consistency for two residents who required modified diets due to dysphagia. For one resident, meal observations revealed that food items such as beef, vegetables, tomatoes, and bean sprouts were not chopped to the required size, with some pieces exceeding the defined chopped consistency. Multiple staff members, including Certified Nurse Aides and the Infection Prevention Coordinator, confirmed that the food items did not meet the expected chopped consistency, referencing standards such as 'less than one inch by one inch' or 'sugar cube sized.' For another resident, similar issues were observed, with food items on both lunch and breakfast trays being inconsistent in size and not appropriately chopped. The Executive Chef stated that there was no specific reference size for chopped consistency, despite the IDDSI framework defining bite-sized pieces as no larger than 15 mm. These observations and staff interviews demonstrated that the facility did not consistently prepare food according to the prescribed diet modifications for residents with dysphagia.
Failure to Document Refrigerator Temperatures on Evening Shift
Penalty
Summary
The facility failed to check and document the refrigerator temperature for one of five kitchen refrigerators during the evening shift for two consecutive days. During an initial kitchen walkthrough, it was observed that the temperature log for refrigerator #10 was missing PM temperature readings and staff initials for two specific days. The Executive Chef was unable to explain the omission, suggesting it may have been related to a new system implemented since his start. Both the Executive Chef and the Director of Nursing confirmed in interviews that refrigerator temperatures are required to be checked and recorded every day on both AM and PM shifts to prevent food spoilage.
Failure to Dispose of Soiled Items and Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices in two separate incidents. In the first incident, a soiled incontinence bed pad was not discarded appropriately after use; instead, it was placed on a resident's personal belongings and left visible to visitors. According to the facility's policy, such items should be securely wrapped in a plastic bag and discarded as regular trash, and the Infection Preventionist confirmed that leaving dirty items on personal belongings is an infection control concern. In the second incident, a staff member did not use the required personal protective equipment (PPE) while providing direct care to a resident under enhanced barrier precautions (EBP) for a skin rash. The staff member was observed showering the resident while wearing only gloves and a surgical mask, omitting the required gown as indicated by the EBP signage. The resident had a history of a rash with possible diagnoses including dermatitis and shingles, and was under EBP at the time of the observation. The Infection Preventionist and RN confirmed that full PPE, including a gown, should have been used during such care.
Failure to Accurately Document and Assess Use of Bed/Chair Alarms for Fall Prevention
Penalty
Summary
The facility failed to ensure that a resident's comprehensive assessment accurately reflected the use of bed and chair alarms as interventions for falls. Despite documentation in progress notes and incident reports that staff were utilizing these alarms, the interventions were not included in the resident's care plan until after multiple falls had occurred. Additionally, the quarterly Minimum Data Set (MDS) assessment did not indicate the use of bed or chair alarms, even though progress notes during the assessment period documented their use. The Director of Nursing confirmed that the alarms should have been included in the MDS assessment based on the available documentation. The resident involved had a history of recurrent falls and sustained a left femur fracture requiring surgery following an unwitnessed fall at the facility. After re-admission post-surgery, new interventions were not developed, and the resident experienced two additional unwitnessed falls prior to discharge. The lack of accurate documentation and assessment of the use of bed and chair alarms as fall prevention interventions contributed to an incomplete and inaccurate assessment of the resident's status and care needs.
Failure to Revise Care Plans After Significant Changes in Condition
Penalty
Summary
The facility failed to revise and update the comprehensive person-centered care plans for two residents following significant changes in their conditions. One resident, who had a history of recurrent falls, sustained a major injury—a left femur fracture—after an unwitnessed fall. Upon readmission following surgery, the facility did not develop or document new interventions in the care plan, despite the incident report listing additional measures such as bed in lowest position, fall mat, clip alarm, and bed sensor alarm. The care plan continued to reflect only the standard interventions that were already in place prior to the injury. As a result, the resident experienced two more unwitnessed falls before discharge. The facility's own Fall Prevention Policy required nursing to review and update the care plan after a fall, which was not done in this case. Another resident with an indwelling urinary catheter did not have their care plan revised to include catheter care after the device was reinserted. Although physician orders specified catheter care every shift, and the resident had the catheter for over a month, the care plan was not updated to reflect this need. Both the RN and DON confirmed that the care plan should have been revised to include catheter care, as it is essential for reflecting the resident's current needs and ensuring appropriate interventions. The facility's policy on care plans also required changes to be made as necessary following significant changes in condition or needs, which was not followed.
Failure to Prevent Accidents and Update Care Plans After Falls
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, a cognitively intact female with quadriplegia and contractures, was inappropriately transferred by a single CNA using a manual transfer instead of the required two-person mechanical lift. The CNA was unfamiliar with the resident, did not receive a proper handoff report, and did not check the Kardex for transfer instructions, resulting in the resident falling and sustaining a right ankle fracture. Another resident with a history of repeated falls, dementia, and osteoarthritis was admitted following a fall and fracture. After a subsequent fall with a major injury (left femur fracture), the facility failed to update the care plan with new interventions to address the increased fall risk. Although interventions such as bed in lowest position, fall mat, and alarms were documented in incident reports, these were not consistently included in the care plan or implemented. The resident experienced two additional falls, with documentation showing that interventions like fall mats and alarms were either not in place or not functioning as intended at the time of the incidents. Interviews with the DON confirmed that the care plans were not revised to include new interventions after significant falls, and that interventions listed in incident reports were not always reflected in the care plan or implemented. The lack of proper communication, failure to follow established transfer protocols, and inadequate updating and implementation of fall prevention interventions contributed to the residents' injuries.
Inaccurate Fall Risk Assessments by Nursing Staff
Penalty
Summary
The facility failed to ensure that nurses and nurse aides demonstrated appropriate competency in completing fall risk evaluations for multiple residents. In one case, a resident with a history of falls and a recent major injury (fractured rib) was assessed as high risk for falls prior to and after the incident, but a subsequent evaluation by an RN recorded a significantly lower score, indicating low risk, without justification. The Director of Nursing confirmed that the evaluation was completed improperly and that staff are expected to question such discrepancies. Similar issues were identified for two other residents: one with a history of recurrent falls and a femur fracture, whose fall risk assessment after a third fall was incomplete and scored much lower than previous assessments, and another resident whose post-fall assessment was also incomplete and showed a lower risk score than prior evaluations. These deficiencies were identified through interviews and record reviews, which revealed that fall risk assessments were not completed accurately or thoroughly, particularly in the areas of gait/balance and medications. The improper completion of these assessments placed the affected residents at risk of avoidable adverse outcomes, as their true fall risk status was not accurately reflected in their care plans.
Failure to Implement Care Plan Leads to Resident Fall
Penalty
Summary
The facility failed to implement interventions in a care plan for a resident, resulting in the resident sustaining an unwitnessed fall. The resident's electronic health record indicated that the fall occurred in the dining room, and the care plan had specified that common areas should be supervised at all times. However, there was a lapse in supervision when the resident's family left, and staff were attending to other residents, leaving the resident unsupervised for a five-minute window during which the fall occurred. Interviews with the Nurse Manager and a Certified Nurse Assistant confirmed that the resident was left unsupervised, and the care plan interventions were not implemented at the time of the fall. The facility's policy on care plans emphasized the need for staff to implement interventions to achieve care plan goals, but this was not adhered to in this instance. The deficiency highlights a failure in communication and supervision, which are critical components of the resident's care plan aimed at preventing falls.
Inadequate Supervision Leads to Falls in High-Risk Residents
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for two residents, both of whom were identified as high risk for falls. The first resident, a male with severe cognitive impairment and a history of spinal stenosis and arthritis, was left unsupervised in the outdoor courtyard by a CNA. During this time, the resident fell and sustained a head laceration. Interviews with staff confirmed that the resident should not have been left unsupervised, especially given his high fall risk score of 13, which indicates a high risk for potential falls. The second resident, a female with severe cognitive impairment due to Alzheimer's disease and other conditions, also experienced a fall. Her fall occurred in the dining room and was unwitnessed, despite her care plan specifying that common areas should be supervised at all times. The resident had a fall risk score of 15, further emphasizing the need for close supervision. Staff interviews corroborated that residents with high fall risk scores require close supervision, which was not adequately provided in this case.
Failure to Report Change in Resident's Condition
Penalty
Summary
The facility failed to ensure timely treatment and care for a resident, identified as R1, who was diagnosed with a fracture of the left upper arm. R1, a female with a medical history including Moyamoya disease, heart failure, and aphasia, was admitted to the facility and later observed by her spouse to have a limp left arm. Despite the spouse reporting this change to a Certified Nurse Aide (CNA1) on 07/10/24, the CNA did not communicate the change to a licensed nurse. The spouse continued to report the limp arm to various staff members until it was finally communicated to a Registered Nurse (RN1) on 07/12/24, who then assessed the resident and confirmed the fracture through an X-ray. The delay in reporting the change in R1's condition resulted in a failure to provide timely care, as the facility's policy requires staff to report any changes in a resident's condition to the RN on duty. Interviews with the CNA1 and the Director of Nursing (DON) confirmed that the CNA should have reported the condition change immediately, allowing for an earlier assessment and intervention. This oversight in communication and adherence to policy potentially affects all residents in the facility, as it highlights a gap in the process of reporting and responding to changes in resident conditions.
Failure to Use PPE for Resident Under Contact Precautions
Penalty
Summary
The facility failed to ensure that staff members, including contracted staff, adhered to the proper use of personal protective equipment (PPE) for a resident under contact precautions. On July 25, 2024, a Radiologist Technologist (RT) was observed in the room of a resident who was under contact precautions due to left ear mastoiditis and left auricular cancer. Despite the presence of a sign indicating contact precautions and instructions for donning and doffing PPE, the RT did not wear a gown while preparing the resident for X-rays. Additionally, a Certified Nurse Aide (CNA) who assisted the RT was also not wearing a gown. The Director of Nursing (DON) confirmed that staff should wear gowns and gloves when entering a room with contact precautions, regardless of the type of care being provided. The facility's policy on contact precautions, dated March 2024, requires staff to wear a gown whenever there is a possibility of direct contact with the resident or potentially contaminated surfaces. The failure to follow these procedures was observed during the interaction with the resident, who was lying in bed while the RT and CNA interacted with them without the appropriate PPE.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 171 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Honolulu
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Maunalani Nursing And Rehabilitation Center | 0.4 mi | ★★★★★ | 1 | 0 |
| Hi'olani Care Center At Kahala Nui | 1.7 mi | ★★★★★ | 0 | 0 |
| Leahi Hospital | 2.2 mi | ★★★★★ | 0 | 0 |
| Arcadia Retirement Residence | 2.6 mi | ★★★★★ | 1 | 0 |
| Islands Skilled Nursing & Rehabilitation | 2.6 mi | ★★★★★ | 13 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.